SUS PBR REFERENCE MANUAL
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SUS PbR Reference Manual v1.3 Contents Introduction 9 This Document 9 Secondary Uses Service (SUS) 9 Payment By Results (PbR) 9 Coverage 9 Coding and Submitting Patient Data 10 Pricing 10 Currency 10 Impact of PbR 10 SUS Payment by Results (PbR) 11 SUS Extract Mart (SEM) 11 Submitting CDS Data 13 Introduction 13 Commissioning Data Sets (CDS) 13 CDS Types 13 Submission Timetable 13 Reconciliation and Post-reconciliation points 14 Reconciliation 14 Post-reconciliation 14 Flowing Data to Support Locally Priced Activity 14 Spell Construction 17 Introduction 17 Spells 17 Slab Logic 17 Slabs 17 Slab 0 - Day Case 17 Slab 1 - NHS Number (Ordinary Admission) 17 Slab 2: Provider Spell Number, DoB & Person Gender Current (Ordinary Admission) 18 Slab 3: Local Patient Identifier & DoB (no longer used) 18 Slab 4: DoB, Person Gender Current, Validated Postcode (no longer used) 18 Slab 5: Confidential Patient 18 Slab 6: Same Day Admissions 18 Slab 7: Regular Admissions 18 Numbering and Ordering 19 Application of Slabs 0, 7 and 5 – Single Episode Spells 19 Copyright © 2014, Health and Social Care Information Centre. All rights reserved. 3
SUS PbR Reference Manual v1.3 Application of Slab 6 - Same Day Admissions 19 Example Scenarios 19 Application of Slabs 1, 2 and Zero LoS Rules 20 Global Validation Rules 24 Overlapping Episodes 24 Missing Episodes 24 Validation, Processing and Data Quality 27 Introduction 27 Applicable Patient Care Settings 27 Validation 27 XML Schema Validation 27 SUS Business Rules 27 SUS Processing 27 HRG Validation 28 Derivations 28 Types of Derivations 28 Counts 28 Data Quality 29 Data Quality Flags 29 Data Cleansing 29 Critical Care 29 HRG Grouping 30 SUS Data Quality Dashboards 30 Tracker 30 HRG Grouping 31 Introduction 31 HRGs 31 HRG Design 31 The Casemix ‘Local’ Grouper 31 Grouper Processing 31 Simplified Grouping Diagram 31 Validation 32 Radiology Pre-processing 32 Pre-processing: 32 Unbundled Activity: 32 Grouping 32 Assign Flags (BPT, SSC, PBC) 32 Unbundled HRGs 32 4 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 ‘Differences’ between the SUS Grouper and Local Grouper 33 Critical Care 35 Introduction 35 PbR Critical Care Extract 35 CC Types and CC Periods 35 Derived PbR Data Items 36 Linkage to Episode/Spell Extracts 36 Validation of Submitted Data 37 SUS Critical Care Processing Summary 37 Counting and Allocating Critical Care Days 38 Grouping 40 Grouping Logic 40 NCC and PCC Daily Records 40 ACC ‘Per Diem’ Multiplier 40 Overlapping in Grouping 40 PbR Final Adjusted Length of Stay 41 Calculation 41 Zero Floor Limit 41 PbR Adjustment 41 Overlapping Critical Care Periods 41 PbR Critical Care Indicators 42 Further Information: 46 Best Practice 47 Introduction 47 Best Practice Tariffs 47 Best Practice Tariffs in Extracts 47 Best Practice Tariff Indicator Actions: 47 Ineligible Combinations 48 Cataracts Best Practice Pathway 48 BP - Cataracts Extract 49 Global BPT Processing 49 Length of Stay Checks 49 Age Checks 49 Short Stay Emergency 49 Short Stay Emergency Tariff 50 APC Mandatory Tariff 50 BPT and SSC Flags 50 Count Data Items 50 Copyright © 2014, Health and Social Care Information Centre. All rights reserved. 5
SUS PbR Reference Manual v1.3 Output Limits 51 Readmissions 53 Introduction 53 Defining Readmissions 53 NHS Number 53 Constructing Readmission Pathways 54 ‘Frozen’ Data 54 RAP Identifier and RAP Sequence Number 55 PARENT-CHILD Relationships 55 Spell Ordering Within Pathways 56 Multiple Same Day Admissions 56 Policy Exclusions: CHILD Spell 56 Patient Age 57 Core HRG 57 Unbundled HRG 57 Primary Diagnosis 57 Country Code 57 Policy Exclusions: PARENT Spell 58 Spell in PbR / Not in PbR (PbR Qualified Indicator) 58 Core HRG 58 Primary Diagnosis 58 Spell Unbundled HRG 58 Discharge Method 58 Main Speciality Code (MSC) 59 Country Code 59 Admission Subtype 59 Treatment Function Code (TFC) 59 Non SUS-Applied Policy Exclusions 59 Identifying Non-Payment Activity 59 RAP DH Tariff Adjustment Child 60 RAP DH Tariff Adjustment Parent 60 Identifying Transfers 60 RAP Spell Transfer Out 61 RAP Spell Transfer In 61 Rules and Flags 61 Example: 61 Readmissions in Extracts 62 Access 62 NHS Number 62 6 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 Available Data Items 62 APC Spells Extract 63 Reconciling SUS PbR with Local Systems 65 Introduction 65 Methodology 65 Causes of Differences 66 Consistent Data 66 Differences in Output from PbR and SEM Data Marts 67 SUS PbR – Processing Issues 68 Net Change 68 Data Consistency 69 Identifying Organisations and Reasons for Access 69 Reasons for Access 69 Spell Construction 69 Spell Construction Anomalies 70 Incorrect Data Preparation for Local HRG Grouping 71 Identification of Activity to Tariff 71 Provider Requested Exclusions 71 Glossary 73 Copyright © 2014, Health and Social Care Information Centre. All rights reserved. 7
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Introduction Secondary Uses Service (SUS) The Secondary Uses Service (SUS) is the This Document central repository which supports the flow of Commissioning Data Sets (CDS) between The SUS PbR Reference Manual has providers and commissioners. been designed to meet user needs as expressed in the SUS PbR User Documentation Survey conducted in Payment By Results (PbR) autumn 2013. Payment by Results (PbR) provides a transparent, rules-based system for paying The purpose of this document is to NHS funded care in England. consolidate existing information and introduce guidance in new or previously It rewards efficiency, supports patient unexplored areas. It should therefore be choice and diversity and encourages considered as a ‘living’ document which can activity for sustainable waiting time be updated in response to further user reductions. feedback. New chapters can be produced and existing chapters enhanced based on Payment is linked to activity and adjusted user requests. for casemix. This ensures a fair and The development of new user support consistent basis for hospital funding rather materials will also be used as a basis for than being reliant principally on historic how we will support users during and after budgets and the negotiating skills of transition to the National Tariff System individual managers. (NTS) which will replace the existing SUS service in the long term. PbR is the payment system in England under which commissioners pay healthcare SUS users are therefore encouraged to providers for each patient seen or treated, provide feedback and suggestions for areas taking into account the complexity of the of improvement in existing guidance and patient’s healthcare needs. The two new requirements for support materials. fundamental features of PbR are nationally These requests will be addressed by determined currencies and tariffs. resources dedicated to improving support Currencies are the unit of healthcare for for users across the SUS and future which a payment is made, and can take a replacement and NTS systems, in terms of number of forms covering different time PbR, SUS system usage, access, analysis periods from an outpatient attendance or a and training. stay in hospital, to a year of care for a long term conditions. Tariffs are the set prices To get in touch and ensure your query is paid for each currency. appropriately addressed, please contact HSCIC enquiries and include ‘SUS User Documentation Feedback' in your email Coverage subject line. PbR currently covers the majority of acute healthcare in hospitals, with national tariffs firstname.lastname@example.org for admitted patient care, outpatient attendances and accident and emergency. This activity is submitted using Commissioning Data Sets (CDS). Current policy intends that the scope of PbR and national tariff will expand in future by introducing currencies and tariffs for mental health, community and other services. 9 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 Coding and Submitting Patient Data services, or to support particular policy When a patient is discharged, a clinical goals. coder working in the hospital translates their care into codes. Two classification Currency systems, ICD-10 for diagnoses and OPCS- The currency for admitted patient care, 4 for procedures (interventions) are used. outpatients and A&E is Healthcare When a patient attends an outpatient clinic, Resource Groups (HRG). HRGs are their Treatment Function Code (TFC) is clinically meaningful groupings of similarly recorded. diagnoses and interventions that consume similar levels of NHS resources. Grouping For some outpatients it is appropriate to the extensive and growing number of record procedures performed as these will clinical codes into HRGs allows tariffs to be allocate an HRG that is priced under set at a sensible and workable level. For different rules to standard OP attendances. APC each HRG covers a spell of care, from This information, together with other admission to discharge. information about the patient such as age and length of stay, is sent to SUS via CDS. Extract reports produced by SUS allow Impact of PbR commissioners to pay providers for the Before PbR, it was common practice for work they have done or to adjust any commissioners to have block contracts with regular monthly payments for actual activity hospitals where the amount of money undertaken. received by the hospital was fixed irrespective of the number of patients Pricing treated. PbR was introduced to: Tariff prices have traditionally been based Support patient choice by on the average cost of services reported by allowing the money to follow the NHS providers in the mandatory annual patient to different types of reference costs collection. In practice, provider. various adjustments are made to the average of reference costs, so final tariff Reward efficiency and quality by prices may not reflect published national allowing providers to retain the averages. The reference costs from which difference if they could provide the tariff is produced are three years in the required standard of care at a arrears. Therefore an uplift is applied which lower cost than the national price. reflects pay and price pressures in the NHS, and includes an efficiency requirement. The introduction of best Reduce waiting times by paying practice tariffs in 2010/11 began to providers for the volume of work introduce the policy concept that tariffs done. should be determined by best clinical practice rather than average cost. Re-focus discussions between commissioner and provider away The tariff received by the provider is from price and towards quality multiplied by a nationally determined and innovation. market forces factor (MFF). This is unique to each provider and reflects the fact that it PbR was introduced to support healthcare is more expensive to provide services in policy and the strategic aims of the NHS. some parts of the country than in others. As these have changed and developed There may also be other adjustments to the over time, so has PbR. The tariff is now tariff for long or short stays, for specialised seen increasingly as a vital means of supporting quality outcomes for patients 10 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
and delivering additional efficiency in the NHS. PbR is not unique to England. Many other countries in Europe, North America and Australasia operate similar payment systems. SUS Payment by Results (PbR) SUS PbR is collection of rules, processes and dedicated data marts that support implementation of PbR policy. Derivations, tariffs and business rules agreed with NHS England and Monitor provide a common and consistent mechanism to support reconciliation of activity and payment between providers and commissioners. SUS PbR produces managed versions of the data, generated at specified cut off points known as the Reconciliation and Post-Reconciliation (final reconciliation) points to produce static snapshots. It can additionally provide a current view of the data held within SUS. All of these are available via the SUS PbR Online service. SUS Extract Mart (SEM) SEM returns the data submitted to SUS with a limited number of additional derivations. These derivations include the core spell and episode HRG derived by SUS PbR and the GP Practice and organisation codes derived by the Personal Demographic Service (PDS). As SEM is updated by each subsequent version of activity data submitted, it reflects the position within SUS at the time the extract is taken and thus provides a changing view over time. Data extracted from SEM will show the same position to that extracted from the PbR Current mart. 11 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
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Submitting CDS Data according to the Commissioning Data Set Mandated Data Flows guidelines available on the Data Dictionary website. Introduction Data is submitted to SUS via Commissioning organisations need access Commissioning Data Sets (CDS). to data to monitor Non-Contract Activity as Comprehensive information on CDS part of the management of their NHS standards can be found in the NHS Data service agreements, and to monitor in-year referral requests to investigate the sources Dictionary. and reasons for Non-Contract Activity. www.datadictionary.nhs.uk The Department of Health requires For further details about setting up CDS accurate data for all patients admitted, flows and more information about treated as out-patients or treated in submission and use of SUS, please refer to accident and emergency by health care the SUS Essentials guide, which can be providers, including patients receiving found on the SUS Guidance pages of the private treatment. The Commissioning Data HSCIC website. Sets also include NHS patients treated electively in the independent sector and www.hscic.gov.uk/susguidance overseas. Commissioning Data Sets CDS Types (CDS) The Commissioning Data Sets are used for The purpose of the Commissioning Data the submission of commissioning data to Sets (CDS) is to enable conformant health SUS and are designed to be capable of activity information to be generated across individually conveying many different the country, independent of the structures encompassing: organisation or system that maintains it. Admitted Patient Care This enables health care professionals to Outpatient Attendances measure and compare the delivery and Accident and Emergency quality of care provided and to support Attendances (Emergency them in sharing information with other Medicine) health professionals and organisations. Future Attendances Commissioning Data Sets currently support Elective Admission List data the following activities: Monitoring and managing NHS Submission Timetable Service Agreements Submission of data to SUS is managed via Developing commissioning plans a submission timetable which is published Supporting the Payment by annually on the SUS PbR Guidance page. Results processes www.hscic.gov.uk/sus/pbrguidance Underpinning clinical governance Understanding the health needs of This timetable defines the Inclusion Date the population (the deadline for data submissions for Reporting waiting time measurement inclusion in SUS PbR Managed Service Extracts) and Publication Date (the Information on care provided for all patients guaranteed SUS PbR publication date for by health care providers (both NHS Trusts Managed Service Extracts). and Independent Sector Healthcare Providers for NHS patients only) must be submitted to the Secondary Uses Service 13 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 Reconciliation and Post- Flowing Data to Support reconciliation points Locally Priced Activity PbR operates a two phase reconciliation Introduction process to arrive at a final agreed position Providers and commissioners wishing for each month's activity. to identify activity that may be subject to Reconciliation local pricing arrangements can do so within normal CDS submissions. Providers submit initial data to SUS related to activity in a calendar month. At a Following agreement between providers nationally determined deadline as and commissioners on rules by which mentioned above, the inclusion date, a specified services are identified, the snapshot of this data is taken and extracts provider applies that agreed coding to are produced for both providers and appropriate activity within a CDS commissioners. The point at which this first submission. snapshot is taken is referred to as either the This may involve the inclusion of items that reconciliation (or flex) point. do not flow in the CDS but which are Post-reconciliation routinely available in the provider’s source Providers and commissioners agree systems, such as codes for wards or clinics between themselves which payments are to in which commissioners may have agreed be made by whom during the reconciliation for specialised activity or activity supporting period. Providers are responsible for re- a particular local initiative to be carried out. submitting data to SUS reflecting the This locally identified activity may or may agreements made with the commissioners. not be subject to extra payment which could At a second nationally determined inclusion not otherwise be identified from data items date, for that month, a second snapshot of included in the standard CDS message. the data is taken and again extracts are produced for both commissioners and Example Scenario providers. This second snapshot point is A provider may have a problem with ‘Did referred to as either the post-reconciliation Not Attends’ in a children’s ENT (Ear Nose (or freeze) point and Throat) service. In agreement with the main commissioner, clinics are set up to run out of hours in the early evening which involves overtime payments to clinic staff. The commissioner agrees to an additional payment to meet these extra costs. Without use of the Service Agreement data items, these appointments would appear alongside regular ENT attendances. Using the Service Agreement Details the provider can identify appropriate records by populating the NHS Service Agreement Line Number data item with an agreed code that identifies the extra clinics. Alternatively, Provider Reference Number could be populated with the agreed code. Locating the Data Items The data items used for this purpose are carried in the Service Agreement Details 14 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
section of all CDS messages. This can be provider and commissioner pair using the viewed in the NHS Data Dictionary. agreement. CDS DATA GROUP: Activity Type - Service Agreement Details: Details of the Service Agreement for the Activity Type Mandatory/ Optional Data Item Format COMMISSIONING SERIAL M NUMBER an6 NHS Service Agreement Number: A number used to uniquely identify a NHS SERVICE AGREEMENT by an ORGANISATION acting as commissioner of patient care services. NHS SERVICE AGREEMENT LINE O NUMBER an10 The NHS SERVICE AGREEMENT LINE NUMBERS may be used to identify a specific NHS SERVICE AGREEMENT reference where the main identifier refers to a general omnibus agreement. PROVIDER REFERENCE O NUMBER an17 A convention agreed locally between a provider and commissioner for use within a CDS message. COMMISSIONER M REFERENCE NUMBER an17 A number (alphanumeric) allocated by the commissioner to a REFERRAL REQUEST. ORGANISATION CODE an3 or M (CODE OF PROVIDER) an5 The ORGANISATION CODE of the Healthcare Provider receiving the PbR tariff income. ORGANISATION CODE (CODE OF an3 or M COMMISSIONER) an5 the ORGANISATION CODE of the original commissioner to support Equals Sign Exclusions The ‘=’ sign convention, used by providers to exclude activity from PbR, is not affected by using this locally priced activity identification method. Sensitive Data Use of local codes in the above data items should not identify sensitive treatments. Codes that identify the nature of the sensitive activity (e.g. HIV Clinic) would not be acceptable. The use of numeric coding schemes is recommended where the descriptions are shared locally between the 15 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
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Spell Construction Slabs The different ‘Slabs’ used by SUS PbR in Introduction spell construction are as follows: SUS PbR spell construction uses data Slab 0 - Day Case items submitted on the CDS record and ‘slab logic’ to enable differentiation A day case refers to a patient that has been between patients and identify and admitted electively and who does not stay aggregate related CDS episodes into overnight as intended. SUS PbR Spells. A tariff can then be applied to the determines a day case based on the resulting spell. following criteria: Spells Patient Classification = 2 (Day Case Admission) A spell is a continuous period of care for a patient at a given provider. Episode Duration = 0 (Discharged on same day) Admitted Patient Care spells can be constructed from one or multiple episodes. Admission Type = ELE (elective) derived where Admission Method value is one of Emergency Medicine (EM) (Accident & 11 (Waiting list), 12 (Booked), or 13 Emergency, A&E) and Outpatient (OP) (Planned). records are also assigned to spells, even though they are always defined as single NON (non-elective) or NULL admission attendances. EM and OP spells therefore types cannot be classified as day cases, always consist of a single ‘episode’ of care. even those with zero LoS. This is also the case with CDS 160 (Other Day case episodes are considered as Delivery Event) activity where a spell single episode spells with zero LoS and always consists of a single episode. are therefore not combined with other episodes. 1 day case = 1 spell. A multiple birth delivery, recorded in CDS 160, would still be classified as a single episode spell. Slab 1 - NHS Number (Ordinary Slab Logic Admission) A concept known as ‘Slab Logic’ is used to In an ‘Ordinary’ Admission a patient has a construct spells based on submitted CDS non-elective admission or is admitted data. electively with the expectation they will stay at least one night (even if during their SUS uses 'slab' logic to match patient admission it is decided the patient will not activity by using the slab-specific data items stay overnight). (detailed in the following section) together with the standard data items used in spell Slab 1 uses NHS Number to identify the construction: patient and (in conjunction with the standard spell construction data items) Provider Code assigns episodes to spells. Admission Date Discharge Date 95% of spells use Slab 1 spell construction Episode Number logic. Last Episode In Spell Indicator The main determinant for assigning episodes for the same patient into the same spells is length of stay (LoS). 17 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 Slab 2: Provider Spell Number, DoB & Episode Number = 1 (provider has Person Gender Current (Ordinary indicated the record is the first Admission) episode in the spell) In certain circumstances, for instance Last Episode in Spell Indicator = 1 where NHS Number is not present or (provider has indicated the record invalid, ‘ordinary’ admission spells can be is also the last episode in the constructed by using a combination of the spell) following data items as a proxy for NHS Number: Episode Start Date = Episode End Provider Spell Number Date (episode duration = 0) Date of Birth Person Gender Current Episode Start Date = Spell Admission Date AND Episode End These data items are used in conjunction Date = Spell Discharge Date (spell with the standard spell construction data LoS = 0) items to construct spells. If all the above criteria are met a single Slab 3: Local Patient Identifier & DoB episode spell is created. No additional episodes will ever be assigned to this spell (no longer used) even if further episodes are submitted for Slab 4: DoB, Person Gender Current, the same provider with the same admission Validated Postcode (no longer used) date. Analysis using 2009/10 data showed that Slabs 3 and 4 were so rarely used they were no longer necessary and were Slab 7: Regular Admissions therefore removed from processing. A Regular Admission is identified where a patient has an elective admission and stays less than one day for Regular Day Slab 5: Confidential Patient Admissions or less than two nights for Regular Night Admissions. Records flagged as Confidential Patient in the CDS record always create a single episode spell because it is not possible to A Regular Admission is defined by the link them to other episodes due to the following rules: removal of identifiable data. Confidential Admission Type = ELE (elective) derived Patient data should therefore be considered where Admission Method value is 11 carefully as it may lead to multiple charging (Waiting list), 12 (Booked), or 13 (Planned). for the same ‘spell’. And (Patient Classification = 3 (Regular Day Slab 6: Same Day Admissions Admission) with an Episode Duration of As part of Slab 6 logic, SUS PbR applies less than 1 the following rules to an incoming episode Or to identify zero LoS episodes that should create a single-episode spell: Patient Classification 4 (regular night admission) with an Episode Duration of Episode is not flagged as less than 2) confidential or a day case All Regular Admissions form single episode spells. 18 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
Numbering and Ordering Application of Slabs 0, 7 and 5 Slab numbering identifies the order in which – Single Episode Spells the slabs were developed over time in the The rules for of Slab 0, 7 and 5 are clearly iterative releases of SUS. However, SUS defined and episodes that fall into these PbR does not apply spell construction categories are easily identified. As processing in this order. Ordering is mentioned above, all result in single important because a spell will be episode spells. constructed based on the first ‘slab’ for which the criteria is met. If a record fails to Application of Slab 6 - Same meet the required criteria for the first Slab the next Slab is considered until one is Day Admissions found whose criteria for construction is met The purpose of Slab 6 is to apply a set of by the record. rules to episodes with zero LoS and use The order in which SUS PbR attempts to information submitted by the provider on construct spells using slab logic is as the CDS record to determine whether a follows: single episode spell should be created or whether there is the potential to assign other episodes to the spell to create a multi- episode spell. Slab 6 logic can therefore Data In create single episode spells for (some) zero LoS episodes and prevent other episodes being incorrectly added to a genuine single Slab 0: Daycase episode spell. In each of the following scenarios, the episodes relate to a single patient (same Slab 7: Regular Admissions NHS Number). Slab 5: Confidential Patient Example Scenarios Scenario 1: Two episodes submitted for Slab 6: Same Day Admissions the same patient and both meet Slab 6 criteria: 1st Episode Received: Slab 1: NHS Number Episode Spell Episode Episode Episode (Ordinary Admission) NHS No. Episode Version Version Start End Length 121 E1 1 1 02-Apr 02-Apr 0 Last Admi Disch Episode Episode Slab 2: Provider Spell, Date of Date Date LoS Number in Spell Spell ID 02-Apr 02-Apr 0 1 1 S100 Birth and Person Gender Current Outcome:Single episode spell created (Ordinary Admission) using Slab 6. Spell Created 19 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 2nd Episode Received: Episode 2 (E2) does not meet Episode Spell Episode Episode Episode Slab 6 criteria. NHS No. Episode Version Version Start End Length 121 E1 1 1 02-Apr 02-Apr 0 A new spell (S400) is created 121 E2 1 1 02-Apr 02-Apr 0 with the potential for further Last episodes to be added. Admi Disch Episode Episode Date Date LoS Number in Spell Spell ID If any of the criteria for Slab 6 are not met, 02-Apr 02-Apr 0 1 1 S100 usual spell construction rules apply. 02-Apr 02-Apr 0 1 1 S200 Outcome:Spell construction for Slab 6 prevents any further episodes Application of Slabs 1, 2 and being assigned to Spell S100. Zero LoS Rules However Episode Number = 1 This section provides example scenarios to and Episode Duration = 0 so demonstrate how spell construction rules meets Slab 6 criteria. are applied to zero LoS spells that do not A new spell (S200) is created, meet Slab 6 criteria. In each scenario, the also with no further episodes to episodes relate to the same patient (same join. NHS Number) admitted to the same provider. There are a number of scenarios where Scenario 2: Two episodes submitted for same day admissions result in the the same patient but only one meets assignment of multi-episode spells. As Slab 6 criteria: previously stated, any episode that has met Slab 6 criteria (thus creating a single episode spell) IS NOT subject to the 1st Episode Received: following rules. Episode Spell Episode Episode Episode NHS No. Episode Version Version Start End Length The following section highlights different 122 E1 1 1 Last 04-Apr 04-Apr 0 potential scenarios and how incoming Admi Disch Episode Episode record data and spell construction rules are Date Date LoS Number in Spell Spell ID used to determine: 02-Apr 02-Apr 0 1 1 S300 In what circumstances the Outcome:Single episode spell (S300) episodes will be assigned to a created using Slab 6. single spell or create separate 2nd Episode Received: spells Episode Spell Episode Episode Episode NHS No. Episode Version Version Start End Length Grouping and Pricing Implications 122 E1 1 1 04-Apr 04-Apr 0 122 E2 1 1 04-Apr 05-Apr 1 The impact of updates to the spell Last (additional or resubmitted activity) Admi Disch Episode Episode Date Date LoS Number in Spell Spell ID 04-Apr 04-Apr 0 1 1 S300 The following factors affect whether single 04-Apr 05-Apr 0 2 1 S400 or multiple spells are created: Outcome:Spell construction for Slab 6 Episode duration and the PbR prevents any further episodes Spell LoS derived from Episode being assigned to Spell S300. Start and End Dates Episode Number 1 and Episode Duration = 1 so 20 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
Episode Number (used to other admissions on the same day populate grouper input field (Slab 0 logic). Same Day Epiorder) Admissions logic (Slab 6) is not applied to day cases or spells Last Episode In Spell Indicator constructed using Confidential where: Patient (Slab 5) logic or Regular o 1 = Last episode in the Admissions logic (Slab 7). hospital provider spell o 2 = Not the last episode in Providing all episodes are APC, the hospital provider spell CDS Type is not considered o 9 = Not known during spell construction. Therefore an episode with CDS Type 130 (Admitted Patient Care - Whether the episodes came in on Finished General Episodes) can the same or different interchanges be assigned to a spell with an episode of CDS Type 140 The final point may seem irrelevant with (Admitted Patient Care - Finished regard to spell construction but spell Delivery Episodes). construction logic has no concept of chronological ordering of episodes. Episode An episode with an NHS Number records are not necessarily submitted to can still be assigned to a spell SUS in the order in which they occurred in with an episode where NHS time and are therefore processed based on Number is not present. For the interchange in which they were example, an episode that has no received. Episodes may be received on the NHS Number but satisfies Slab 2 same or a different interchange. criteria will create a spell. If another episode is received with Spell construction is therefore effectively NHS Number, it will be assigned to driven by the order of processing. This is the same spell (assuming SUS demonstrated in the following examples. PbR finds a match using Slab 2 In the following examples, episode 1 will be logic). considered as the first episode processed even if it happened later in time. Scenario 1a: Single Spell formed from 2 Other considerations when reading this zero LoS Episodes section are as follows: 1st Episode Received: Spell PbR LoS is derived from the Episode Spell Episode Episode Episode Episode Start and End Dates and NHS No. Episode Version Version Start End Length does not take any account of 123 E1 1 1 Last 06-Apr 06-Apr 0 Admi Disch Episode Episode Admission and Discharge Dates. Date Date LoS Number in Spell Spell ID For example, if a spell is created 06-Apr 06-Apr 0 1 2 S500 from a single episode where the Episode Start and End Dates are Outcome:Last Episode In Spell 1 so the same, the spell LoS will be ‘0’ does not meet Slab 6 criteria. even if the Hospital Provider Spell Single Episode Spell created Start and Discharge Dates using Slab 1. suggest a spell of longer duration. Day Case spells will always create a single episode spell, regardless of whether the patient had any 21 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 2nd Episode Received: 2nd Episode Received: Episode Spell Episode Episode Episode Episode Spell Episode Episode Episode NHS No. Episode Version Version Start End Length NHS No. Episode Version Version Start End Length 123 E1 1 1 06-Apr 06-Apr 0 124 E1 1 1 08-Apr 08-Apr 0 123 E2 1 1 06-Apr 06-Apr 0 124 E2 1 1 08-Apr 08-Apr 0 Last Last Admi Disch Episode Episode Admi Disch Episode Episode Date Date LoS Number in Spell Spell ID Date Date LoS Number in Spell Spell ID 06-Apr 06-Apr 0 1 2 S500 08-Apr 08-Apr 0 1 2 S600 06-Apr 06-Apr 0 2 1 S500 08-Apr 08-Apr 0 2 1 S700 Outcome:Again episode 2 does not meet Slab 6 criteria because Episode Outcome:Again episode 2 does not meet Number 1. Slab 6 criteria because Episode However, because the NHS Number 1. Number, Provider and However, because the NHS Admission Date are the same Number, Provider and SUS will assign these episodes Admission Date are the same to the same spell. SUS will attempt to assign these Where multiple episodes with episodes to the same spell. zero LoS are candidates for Where multiple episodes with being assigned to the same spell, zero LoS are candidates for SUS performs a check on being assigned to the same spell, Episode Number. SUS performs a check on Because the Episode Numbers Episode Number. are different the two episodes will Because the Episode Numbers be assigned to the same multi- are the same the two episodes episode spell (S500), created will NOT be assigned to the using Slab 1. same multi-episode spell and (N.B: See Scenario 3b for an example of instead a separate spell (S500) is where Episode Numbers are the same). created using Slab 1. Scenario 2: Separate Spells formed from zero and a non-zero LoS Episodes Scenario 1b: Separate Spells formed from 2 zero LoS Episodes 1st Episode Received: 1st Episode Received: Episode Spell Episode Episode Episode NHS No. Episode Version Version Start End Length Episode Spell Episode Episode Episode 125 E1 1 1 Last 10-Apr 10-Apr 0 NHS No. Episode Version Version Start End Length Admi Disch Episode Episode 124 E1 1 1 Last 08-Apr 08-Apr 0 Date Date LoS Number in Spell Spell ID Admi Disch Episode Episode 10-Apr 10-Apr 0 1 2 S800 Date Date LoS Number in Spell Spell ID 08-Apr 08-Apr 0 1 2 S600 Outcome:Last Episode In Spell 1 so does not meet Slab 6 criteria. Outcome:Last Episode In Spell 1 so does not meet Slab 6 criteria. Single Episode Spell created using Slab 1. Single Episode Spell created using Slab 1. 22 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
2nd Episode Received The NHS Number, Provider and Episode Spell Episode Episode Episode Admission Date are the same NHS No. Episode Version Version Start End Length so SUS will attempt to assign 125 E1 1 1 10-Apr 10-Apr 0 these episodes to the same spell. 125 E2 1 1 10-Apr 12-Apr 2 Last Where a zero LoS episode is Admi Disch Episode Episode assigned to a non-zero LoS Date Date LoS Number in Spell Spell ID spell there is no check on 10-Apr 10-Apr 0 1 2 S800 10-Apr 12-Apr 0 1 1 S900 Episode Number. Outcome:Again episode 2 does not meet Therefore episode 2 will be Slab 6. assigned to the same spell, creating a multi-episode spell The NHS Number, Provider and (S110). Admission Date are the same so SUS will attempt to assign these episodes to the same spell. Scenario 3b: Zero LoS Episode However, spell construction rules Assigned to an Existing Spell Where do not allow a non-zero LoS Episodes Have Same Episode Number episode to be assigned to an 1st Episode Received: existing spell with zero LoS. Episode Spell Episode Episode Episode NHS No. Episode Version Version Start End Length Therefore episode 2 will create a 127 E1 1 1 Last 16-Apr 18-Apr 2 separate spell (S900). Admi Disch Episode Episode Date Date LoS Number in Spell Spell ID Scenario 3a: Zero LoS Episode 16-Apr 18-Apr 2 2 2 S120 Assigned to an Existing Spell Where Episodes Have Different Episode Outcome:Last Episode In Spell 1 so Number does not meet Slab 6 criteria. 1st Episode Received: Single Episode Spell created using Slab 1. Episode Spell Episode Episode Episode NHS No. Episode Version Version Start End Length 2nd Episode Received 126 E1 1 1 Last 12-Apr 14-Apr 2 Admi Disch Episode Episode Episode Spell Episode Episode Episode Date Date LoS Number in Spell Spell ID NHS No. Episode Version Version Start End Length 12-Apr 14-Apr 2 1 2 S110 127 E1 1 1 16-Apr 18-Apr 2 Outcome:Last Episode In Spell 1 so 127 E2 1 1 18-Apr 18-Apr 0 does not meet Slab 6 criteria. Last Admi Disch Episode Episode Single Episode Spell created Date Date LoS Number in Spell Spell ID 16-Apr 18-Apr 2 2 2 S120 using Slab 1. 18-Apr 18-Apr 0 2 1 S120 2nd Episode Received Episode Spell Episode Episode Episode Outcome:Again episode 2 does not meet NHS No. Episode Version Version Start End Length Slab 6 criteria. If episode 2 126 E1 1 1 12-Apr 14-Apr 2 Episode Number = 1 it would 126 E2 1 1 14-Apr 14-Apr 0 have met Slab 6 criteria and Last been assigned to a single Admi Disch Episode Episode Date Date LoS Number in Spell Spell ID episode spell. 12-Apr 14-Apr 2 1 2 S110 14-Apr 14-Apr 0 2 1 S110 The NHS Number, Provider and Admission Date are the same Outcome:Again episode 2 does not meet so SUS will attempt to assign Slab 6 criteria. these episodes to the same spell. 23 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 Where a zero LoS episode is R11. This rule identifies those spells where assigned to a non-zero LoS days lie within the spell boundaries spell there is no check on (Admission Date to Discharge Date) but Episode Number. outside of the episode boundaries. Therefore episode 2 will be Any spell containing one or more days that assigned to the same spell, do not fall within the boundary of an creating a multi-episode spell episode are considered to contain ‘missing (S120). episodes’ and therefore fail this global validation rule. However, this spell fails the grouper check for a unique After ordering the episodes by Episode Episode Number and therefore Start and End Date, SUS PbR applies the generates an UZ01Z HRG (Data following rules. A spell that fails any of Invalid for Grouping). these rules is considered to contain ‘missing episodes’: Start Date of first episode = Spell Global Validation Rules Admission Date Global validation rules are applied on a ‘first strike’ basis. This means that on failing a (For a multi-episode spell), End global validation rule, further rules will not Date of the first episode = Start be applied and the Spell in PbR / Not in Date of the next episode PbR indicator, output in extracts, will reflect the first point of failure, regardless as (For a multi-episode spell), End to whether the record would have gone on Date of the nth episode = Start to fail further global validation rules. Date of the (n+1) episode Spell in PbR / Not in PbR indicator is a derived spell level flag indicating if a spell End Date of the last episode = qualifies for PbR and therefore attracts a Spell Discharge Date tariff. A value of '0' indicates that a spell qualifies for PbR and therefore attracts a Where any of the above are not true, Spell tariff. All other values indicate that the in PbR / Not in PbR (PbR Qualified activity is excluded from PbR. Indicator) is set to 9 (APC Spell with Overlapping Episodes Missing episodes) and the spell core HRG is set to N/A. The spell will not be tariffed. Any spell which contains episodes that overlap by more than one day is excluded This global validation rule is applied to APC from SUS PbR processing and the Spell in spells only (not OP or EM attendances) with PbR / Not in PbR (PbR Qualified Indicator) the following exceptions: is set to 8 (APC Spell with Overlapping APC ‘open’ spells Episode(s)). An Episode End Date which is equal to an Episode Start Date does not APC ‘phantom spells’ (Spell in constitute an overlap. PbR / Not in PbR indicator = 1) The episodes are grouped as single episode spells and the episode HRG is CDS 160 (Other Delivery Event) derived, but the Spell Core HRG is set to N/A. Note: ‘Phantom spells’ are spells where Missing Episodes the episodes have been logically deleted. A further global validation rule to account Global validation rules are applied on a ‘first for missing episodes was implemented in strike’ basis. The Missing Episodes rule is 24 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
applied AFTER the Overlapping Episodes rule and therefore a spell that has both overlapping and missing episodes will be flagged with Spell in PbR / Not in PbR (PbR Qualified Indicator) 8 (APC Spell with Overlapping Episode(s) and will not also be flagged with Spell in PbR / Not in PbR (PbR Qualified Indicator) 9 (APC Spell with Missing episodes). 25 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 26 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
XML Schema Validation Validation, Processing and Submitted data is validated against Data Quality standards specified in the NHS Data Dictionary. Compliance with these Introduction standards is required for data to enter SUS. SUS PbR applies a range of general and XML Schema validation failure will cause PbR-specific validation and processing an entire interchange to be rejected. Data stages to submitted data. Where that fails at this stage will not be sent to submitted activity data is not considered to SUS. be of sufficient accuracy or completeness, Error messages created by the XML interchanges are rejected. Data quality translation software show the reasons for messages are returned to the data sender, validation failure. enabling them to resubmit corrected or completed data. Applicable Patient Care Settings SUS Business Rules Admitted Patient Care (APC) SUS Business Rule validation is performed CDS 120, 130, 140, 150, 160 after XML Schema validation and when Outpatient (OP) data lands at SUS. Individual data items CDS 020 are compared with defined release-specific Future Outpatients reference data item values to ensure that CDS 021 the submitted data meets the required Emergency Medicine (EM) criteria. CDS 010 SUS Business Rule validation failure also results in rejection of the entire interchange. In the same way as with an XML schema Validation failure, the data sender is notified of the Submitted data is validated to ensure that it reason(s) for validation failure via an error conforms to defined standards and can message. therefore be used downstream for reliable Certain validation rules may stop reimbursement and accurate analysis. processing of all interchanges for that Validation ensures that non-compliant sender until the error is resolved. submissions are not allowed into SUS and are rejected. The sender is notified of why the data has failed validation. SUS Processing There are three keys stages in validation: If an interchange successfully completes XML Schema Validation business rule checks it will then be SUS Business Rules accepted into SUS and be added to all HRG Validation relevant data marts. This does not mean all errors within the data have been captured. Data is validated to ensure that it matches It simply means that the data is correctly the defined schema and that the entered formatted and is of sufficient quality for values conform to the required formats and subsequent business processes. Other meet defined criteria. The values allowed checks may discover further problems or for certain data items are defined in inadequacies that prevent full processing reference data and applied within the where a desired value cannot be schema. determined. 27 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 HRG Validation SSC (Specialised Service Code Derivation of valid HRGs relies on data ) items within the submitted patient record. HRG validation failure may lead to the Critical Care derivation of a UZ01Z HRG (Data not valid Critical Care Tariff for grouping). Number of days in Critical Care For more information please refer to the (Critical Care period) (for tariff HRG Grouping section. and length of stay purposes) Reasons for failure to group are found at record level in the online Error extracts Exclusions generated alongside main activity extracts if Exclusion reason the option for this supplement is selected at Excluded value the time of extract configuration. Tariff Derivations The appropriate tariff is determined using Derivations are system-generated data the HRG and other activity characteristics. items that are created by comparing These include patient type (day case, submitted data with applicable ordinary elective or ordinary non elective), corresponding reference data tables and Length of Stay, Treatment Function Code assigning the appropriate derived value. (TFC) and Age Group (derived from Age). There are various types of derivations but in general most of these derived data items Adjustments support PbR by ensuring accurate calculation of tariffs and currency. Adjustments can be derived from: Reference data tables, used to derive PbR HRG specific data items, are updated with each SSC (Specialised Service release of SUS to ensure appropriate Code) coverage. BPT (Best Practice Tariff Indicator) Organisation Code (e.g. Types of Derivations Clinical Commissioning Group (CCG) of responsibility and The following list shows some examples of CCG of residence) the types of derivations in SUS: Age General Length of Stay (e.g. Excess bed days) Spell ID Age These adjustments can have an impact on Length of Stay the assignment of the final tariff. Grouping Counts HRG (Healthcare Resource Group) Counts are similar to derivations but instead BPT (Best Practice Tariff) of deriving a value with which to populate a PBC (Programme Budgeting specific data item, a count of instances for a Category) particular data item is returned as a value. For example Count of Secondary 28 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
Diagnosis is a calculation of the total Dashboard and Tracking tools enable users recorded number of secondary diagnoses to view, monitor and benchmark their data within the patient care record. quality against other providers. SUS PbR extracts contain a maximum of 12 primary and secondary diagnoses or procedures. Further ‘repeating groups’ can Data Quality Flags be found in the Supplementary extract. Possible data quality issues are highlighted by assigning a Data Quality (DQ) flag to the record. This allows users to clearly Examples of SUS PbR Counts: identify issues and resubmit corrected or completed data. BPT flags SSC days Data Quality flags are assigned to missing Length of Stay or problematic records. Records with DQ Secondary diagnoses flags can cause a spell not to be priced by Procedures PbR (even though it may still be grouped). The PbR Error Extract returns records with Investigations the corresponding error reason so that A & E treatment codes senders can correct and resubmit the data. SUS PbR validations and derivations are There is no limit to the number of potentially currently documented in the Indicators, repeating data items being submitted. Errors and Data Quality Guide available Counts enable users to see whether on the PbR Guidance page of the HSCIC further information may be present in the website: Supplementary extract. www.hscic.gov.uk/sus/pbrguidance Counts help increase transparency and in some cases are also used in validation such as calculation of Critical Care days. Data Cleansing For more information about the content of The following examples demonstrate how extracts please refer to the SUS PbR some data quality issues are corrected Extract Specification through the application of standard pre- www.hscic.gov.uk/sus/pbrguidance defined cleansing processing. Diagnosis Codes Data Quality ICD-10 morphology codes are removed. This involves the truncation of incorrectly Data quality is important in ensuring the submitted 5 character codes to 4 character accurate calculation of tariffs and improving codes. transparency around why payment may not have been received for a particular subset Procedure Codes of submitted activity. This allows users to Invalid characters are removed, such as full identify and understand the reasons for the stops in OPCS codes. data quality issues and resubmit revised data in place of missing or inaccurate data. SUS PbR performs a number of data Critical Care quality checks. Data cleansing processes Critical Care data quality checks ensure are limited to formatting clinical codes such that Episode End Date aligns with the that they will be accepted by the grouper. It expected Critical Care treatment end date. is important to note that no other CDS items are changed by SUS processes. 29 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 HRG Grouping interchanges and view Data Quality Checks and exclusions are made based on: Reports (DQR) of the data within. Tracker Reports ‘Illogical data’ such as a day case that covers three days, For convenience, Tracker information is invalid treatment function also provided in snapshot workbook format codes or diagnosis/procedure on the SUS website under Weekly Trust codes which are classified as Statements on the Operational Support other or unspecified pages www.hscic.gov.uk/sus/operationalsupport Data issues and missing data These weekly reports track the status of all data submissions up to the date displayed Rather than rejecting data, it is either in the report heading. They allow the status ‘cleansed’ or ‘flagged’ as containing issues. of all submissions for a particular It then continues through the process and organisation to be checked. Senders are can lead to the derivation of a UZ01Z HRG encouraged to use the Tracker reports to (Data invalid for grouping) and assignment check that data has been successfully of a zero price. received by SUS. This is particularly useful after any organisational or system (PAS or XML) changes have been made. SUS Data Quality Dashboards Monthly Database Counts A number of dashboards have been developed by the HSCIC to support users in Reports are generated and published on a monitoring and driving improvements in the monthly basis to track the number of quality and completeness of SUS data. records submitted to SUS (by activity The dashboards report on the coverage and month) for the last 18 months. Activity is quality of the APC, Outpatient and A&E CDS displayed for each CDS type on a separate types, as well as focussing on other key worksheet and can be used to highlight areas for improvement of data quality such as where an organisation has peaks and Maternity and Critical Care. troughs in activity submissions, has duplicated or deleted data or where an There is no limit to the number of users within organisation has started or stopped an organisation that can register for access to submitting data. the SUS dashboards. More information about how to register can be found under the ‘How www.hscic.gov.uk/sus/operationalsupport do I analyse data quality?’ on the SUS Guidance web page: www.hscic.gov.uk/susguidance Tracker The status of a CDS interchange submission can be monitored using the SUS ‘Tracker’. Tracker can be accessed via the SUS Portal by selecting Service Tracking Reports. It shows the live status of interchanges submitted to SUS and whether they have been processed and made available in the SEM and PbR marts. Users can drill down into these 30 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
HRG Grouping Grouper Processing A number of validation and pre-processing Introduction stages take place before the actual grouping takes place whereby HRG codes HRGs are assigned to patient record data. Healthcare Resource Groups (HRGs) are the ‘currency’ of PbR for Admitted Patient After grouping, Best Practice Tariff (BPT), Care, Outpatient procedures and A&E Specialised Service Code (SSC) and attendances. In the context of PbR Programme Budgeting Category (PBC) ‘currency’ refers to the units of healthcare flags are assigned. for which a payment is made. Simplified Grouping Diagram HRGs are clinically meaningful groupings of patient activity derived from NHS patient Input Data records, primarily using procedure and Patient Activity (Episode &/or Spell Data) diagnosis codes. They support PbR by providing a means of determining fair and equitable reimbursement for healthcare Validation services by providing consistent 'units of currency', based on expected resource use. HRG Design Radiology Pre-processing HRG design is developed and maintained by the HSCIC National Casemix Office, driven by policy and assured nationally Pre-processing through Expert Working Group consultation. (Combinations) The design for each version of the classification is represented by a definitive set of rules and reference data. It is Unbundled Activity implemented by an algorithm, delivered via a software application, which follows design rules to interrogate reference tables to determine whether criteria for candidate Grouping: HRGs are met by the incoming patient record data. Using a process of Multiple Trauma elimination, the most appropriate HRG is Procedure driven determined and assigned to the activity. Global Exception (e.g: PPNCD) The Casemix ‘Local’ Grouper Diagnosis The Casemix Local Grouper is the software application that aggregates patient level Assign Flags (BPT, SSC, PBC) coding information into HRGs. The local grouper performs validation checks before using a complex algorithm to assign HRGs to patient records and Output Data produces output files which contain the Patient Activity with Assigned original input data along with the assigned HRGs and Flags HRGs. It also produces quality files that contain details of any errors or conflicts. 31 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3 Validation Grouping Validation checks are built into the local Grouping is the main stage of the process payment grouper and are applied prior to in which one HRG code is assigned to the the HRG code being assigned to a patient Spell. This is referred to as the core HRG. record. This checks the OPCS codes to Patient record data items, such as ensure they are valid. Reasons why a code procedures, diagnoses, age and length of may not be seen as valid includes: stay are used to determine the appropriate HRG code for the Spell. Logical inconsistency (e.g. paediatric procedure being given to someone Assign Flags (BPT, SSC, PBC) over 18 years old) Best Practice Tariff (BPT) An invalid or missing code has been Most Best Practice Tariff flags are assigned e.g. a Treatment Function generated by OPCS and ICD10 codes, Code that does not exist or clinically These may be required in combination and irrelevant for grouping e.g. family may also require qualification by other history of diabetes. codes, for example site or approach codes. If a deliberately ambiguous OPCS code is used (e.g. Only certain HRGs can be flagged as best diagnosis/procedure ‘unspecified’) practice. In addition age criteria and type of admission will determine whether activity Radiology Pre-processing can be flagged as best practice. Pre-processing occurs for radiology Specialised Service Codes (SSC) activity because it must be mapped to reference data before processing. SSCs are assigned based on the record meeting predefined reference criteria. Pre-processing: Programme Budgeting Categories (PBC) Pre-processing involves creation of combination procedure codes, and logical The grouper maps the Primary Diagnosis of deletes. a patient record to a Programme Budgeting Category (PBC) which is then output by the Unbundled Activity: grouper. There is no direct mapping of Unbundled procedures are processed HRGs to PBCs. The programme budget separately to derive unbundled HRGs (See category allows high level reporting on the Unbundled HRGs). The grouper then amount of money being spent on specific ignores these unbundled components when treatments, such as cancer or heart deriving the core HRG. disease. When all significant procedures in an admitted patient care episode or spell are unbundled, diagnosis is used to derive a Unbundled HRGs core HRG for the episode. For outpatient A pathway of care typically consists of a care, if all procedures are unbundled the number of different service elements such episode is allocated one of the eight as diagnostic imaging, high cost drugs relevant non-admitted care attendance and rehabilitation. Unbundled HRGs HRGs as a core HRG. account for these consumable elements, There can be one or more ‘unbundled’ HRG allowing them to be commissioned, priced codes assigned that can be used to identify and paid for on an individual basis. PbR the use of repeating resource use such as data contains the first 12 unbundled HRG scans. codes generated for the activity. 32 Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
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